Percutaneous laser treatment

ABSTRACT

A method of percutaneous and subcutaneous laser treatment of the tissue of a patient is provided. The tip of an optical fiber is passed through the skin, advanced through the tissue subcutaneously to a desired treatment area and withdrawn. Laser energy can be emitted at different levels during any or all of the skin penetration, advancement, tissue treatment and withdrawal phases. The present invention is useful for surgical treatments, and is especially suitable for minimally invasive plastic or cosmetic surgical and dermatological procedures without bleeding and with less edema, erythema and swelling and faster healing than conventional surface laser energy application, abrasion, scalpel surgery or chemical peel procedures.

TECHNICAL FIELD

The present invention relates to methods and procedures for theamelioration of cosmetic flaws and the like by the application of laserenergy to a selected target region or site. The present invention isuseful in the practice of surgery, especially plastic and cosmeticsurgery, as well as dermatology. The present invention is especiallysuitable for minimally invasive surgical treatments in which apercutaneous approach is desired.

BACKGROUND OF THE INVENTION

Biological tissue comprises cells embedded in a primarily proteinaceousextracellular matrix. Collagen is one of the predominant proteins foundin the extracellular matrix. Collagen can be altered by the applicationof thermal energy to become denatured and act as a biological glue.Thermal energy can also cause collagen fibers to become cross-linked,reducing the volume of the thermally treated collagen. The thermaleffect may be conveniently produced by the interaction of lasergenerated light energy with tissue. Laser energy of the appropriatewavelength, energy and geometry can thus be used to weld togetheropposed tissue surfaces and shrink collagen-containing tissues.

The use of laser devices in various types of surgery is known. Suchdevices cause thermal coagulation and/or ablation of tissue by emissionof a predetermined level of laser energy for a predetermined time. Theunwanted tissue can be coagulated to the desired depth by laser energyat low energy density, or ablated by subjecting the tissue to a higherlevel of energy density. However, when laser energy is applied to theskin from an external source, erythema or sun-burning frequently occurs.The erythema can take weeks or months to subside, and discoloration orscarring of the skin may be a lasting result.

Several plastic surgery procedures involve the surgical removal ofsubcutaneous fat and excess skin and the tightening of the remainingskin. Such procedures include meloplasty (face lifts), eyebrow lifts andblepharoplasty for removal of bags under the eyes (dermochalasis andblepharochalasis). Beyer, C. K., Baggy lids, Int. Ophthalmol. Clin., 10:47-53 (1970). Traditional surgical approaches require cutting andremoving excess skin and fat using incisions often centimeters inlength. These approaches are subject to potential complications such ashemorrhage, hematoma, infection and removal of too much skin or fat(overcorrection). Kohn, R., Textbook of Ophthalmic Plastic andReconstructive Surgery, pp. 177-191, 186, Lea & Febiger, Philadelphia(1988). As an example, surgical procedures for blepharoplasty arecomplex. Inappropriate or poorly performed surgery may result in anadverse cosmetic result, or may place the patient at risk for developingvision-threatening complications. Custer, P. L., Lower eyelidblepharoplasty, in Bosniak, S., editor, Principles and Practice ofOphthalmic Plastic and Reconstructive Surgery, pp. 617-625, 624, W. B.Saunders, Philadelphia (1996).

Lasers have been employed in cosmetic and reconstructive surgery. TheNd:YAG laser has been used to make incisions in the skin for face lifts(meloplasty) and for removal of bags under the eyes by blepharoplasty.Apfelberg, D. B., YAG laser meloplasty and blepharoplasty, Aesth. Plast.Surg. 19: 231-235 (1995). However, the Nd:YAG laser's continuous waveenergy may be overly thermal and cause an excessively deep zone ofpenetration (about 4000 μm). The CO₂ laser has been employed inblepharoplasty using the transconjunctival approach. David, L. M., Thelaser approach to blepharoplasty, J. Dermatol. Surg. Oncol. 14: 741-235(1988). While the use of laser energy has been reported to reducebleeding during surgery and reduce pain during healing, a large incisionis still required. Morrow, D. M., and Morrow, L. B., CO₂ laserblepharoplasty. A comparison with cold-steel surgery, J. Dermatol. Surg.Oncol., 18: 307-313 (1992). The only advantage provided by the describedlaser technique was less swelling after surgery.

What is needed is a method of plastic surgery using a laser thatprovides more desirable tissue effects and which can also be used in aminimally invasive percutaneous approach.

SUMMARY OF THE INVENTION

A percutaneous method for the treatment of skin and subcutaneous tissueby means of a laser device capable of emitting pulses of light energy ofan appropriate wavelength with relatively short pulse widths, atrelatively low energy per pulse and relatively rapid pulse repetitionrates is provided by the present invention. Light energy characterizedby such parameters is applied subcutaneously to tissues underlying theskin. The method is useful for the practice of surgery, especiallyplastic and cosmetic surgery as well as dermatology. The method isnon-invasive or minimally invasive and well suited for outpatienttherapy. In particular, application of the laser energy directly to thetissue beneath the skin eliminates or reduces the erythema that canresult when laser energy is applied to the skin from outside the body.

The method of the present invention is especially suitable for severalprocedures used in plastic and cosmetic surgery as well as dermatology.Procedures for which the method of the present invention can be usedinclude, inter alia, the removal of pigmentation, such as lentigines(age spots), hyperpigmentation, lentigo (freckles), caf{acute over(e)}-au-lait macules, actinic keratosis, melasma, and tattoos (body orfacial). The method of the present invention can also be used for theremoval of plantar warts, chin reshaping via the percutaneous lasermelting or desiccation of fat, amelioration of turkey neck, and thetreatment of some dilated blood vessels associated with rosacea. Themethod of the present invention is also suitable for coagulation ofspider veins (<1 mm), removal of keloid scars, coagulation of varicoseveins (>1 mm), reshaping of the upper lip, reshaping of the eyelids,permanent ablation of the hair follicle to permanently prevent hairregrowth and some types of otoplasty. The method of the presentinvention is also suitably used for the treatment of various cutaneousvascular lesions, such as port wine stains, hemangiomas, andtelangiectasias, including those of the face and the leg.

The method of the present invention can also be used for plastic surgerytreatments such as skin resurfacing, removal of perioral, periorbitaland ear lobe wrinkles, treatment of nasal labial folds, perioral fatpads and marionette lines, lip lift, neck lift, eyebrow lift, lipolysis(of upper and lower eyelids, cheeks, abdomen, thighs), blepharoplasty,rhinoplasty, treatment of polly beak and internal weir (nostrilreduction). Scars that can be treated using the method of the presentinvention include acne scars, keloids, chicken pox scars, stretch marks(striae), hypertrophic scars, and skin graft hypertrophy as well as pitsand depressions. In addition, the method of the present invention isalso suitable for burn debridement, and for the treatment of corns,papilloma (warts, condylomas, polyps) and skin cancer, including basalcell carcinoma.

A pulsed or continuous wave holmium:YAG laser, holmium:YSGG laser orother laser emitting light energy at a wavelength of about 1800micrometers to about 2200 micrometers (“holmium laser”) may beconverted, in accordance with the present invention, to produce pulsesof variable pulse-width at various energy levels. The light energy froma holmium laser has an ideal depth of penetration into tissue, about 250to 400 μm. The holmium laser is a preferred light energy source becauselight energy obtained therefrom has the property of being able to causecross-linking of collagen proteins, lysis of fat and bloodlessincisions, primarily due to the wavelength of light emitted.

Energy from a relatively low power, short pulse-width, high repetitionrate holmium laser, applied percutaneously through an optical fiber, canavoid burning or charring the tissue while accomplishing the desiredbeneficial physiologic effect. At lower energy densities, the collagencomponent of tissue can be cross linked, reducing its volume and causingshrinkage of the tissue. The holmium laser preferred for the practice ofthe present invention provides a marked advantage over earlier surgicaltechniques. Benefits of the holmium laser include less postoperativeswelling, faster healing, no bleeding and no sutures to be removed.Additionally, the method of the present invention allows for the meltingor desiccation of subcutaneous fat by the use of a relatively smalldiameter optical fiber, e.g. a 25-400 μm core diameter, that isintroduced through the skin. The small diameter of the optical fiber,coupled with the low energy used, typically about 3 to 100 milliJoulesper pulse (mJ/pulse), the narrow pulse-width, typically less than 100microseconds (μS), and relatively fast repetition rate, generally 20 to80 pulses per second (Hz), allow the fiber to penetrate the skin and beused subcutaneously upon tissue without perceptible charring as aresult. Preferably, an energy level of about 3 mJ/pulse to about 20mJ/pulse is used while the tip of the optical fiber is inserted throughthe skin. In comparison, most holmium lasers currently used in surgeryare not stable in producing less than 500 mJ/pulse, typically have apulse width of 300 to 350 μS and a repetition rate of 1 to 25 Hz.

The laser source typically comprises a housing containing the lasergenerating unit as well as optical and electronic control componentstherefor. The optical fiber is connected proximally to the light outputof the laser and extends distally through a hand piece held by thesurgeon. The light energy produced by the laser source is introducedinto the proximal end portion of the optical fiber, which itself passesthrough a handpiece, and is emitted from the bare distal tip of theoptical fiber distally to the target tissue. The tip of the opticalfiber preferably has a core diameter of about 25 μm to 400 μm, morepreferably about 50 μm to about 200 μm.

The face of the optical fiber tip is preferably aligned at a right angleto its longitudinal axis. Bleeding at the entry and exit point may beminimized by lasing at extremely low energy, as low as 1 mJ/pulse with avery short pulse width, preferably 10-30μS, during insertion through theskin or withdrawal of the optical fiber from the treatment site whileexiting the skin.

The method aspect of the present invention includes a subcutaneousadvancement phase as well as a withdrawal phase. In use, afterpenetration of the skin as described above, the tip of the optical fiberis moved forwardly through the tissue during the advancement phase.During this phase, the tip of the optical fiber is advanced through thetissue for the desired distance without emission of laser energy or withlaser emission at a controlled power level chosen to achieve the effectdesired. If desired, laser energy can be emitted from the tip during theadvancement phase at a controlled energy level of less than about 3 toabout 20 mJ/pulse, at a frequency of 20 to 80 Hz and a pulse width of 30to 100 μS. A preferred energy emission frequency during the advancementphase is about 20 to 60 Hz. During advancement, very low emission energyof 3-10 mJ/pulse can be used to facilitate the advancement of theoptical fiber and prevent tissue adherence to the optical fiber. Ifdesired, laser energy to obtain a desired therapeutic effect can beemitted at an energy of 5 to 50 mJ/pulse.

The tip of the optical fiber may be maintained at the position offurthest advance and laser energy emitted there, or alternatively, thetip may be immediately withdrawn. During the period while the tip of thelaser probe is being used to treat the tissue at a selected site, laserenergy can be emitted at an energy of about 5 to about 50 mJ per pulseat a frequency of about 20 to about 60 Hz. During the withdrawal phase,laser energy can be emitted at about 5 to about 50 mJ/pulse at afrequency of about 20 to about 60 Hz, depending on the tissue effectdesired, or at about 3 to about 10 mJ/pulse to prevent tissue adheringto the fiber during withdrawal. In other cases, the fiber can bewithdrawn without using laser energy. The energy level can also bechanged as the fiber moves from one area to another under the skin toobtain a desired effect. It is not necessary to remove the opticalfiber, or to turn off the laser while the surgery is being performed.

In general, the level of light energy emitted during the withdrawalphase is equal to or greater than the emission level, if any, during theadvancement phase. The power output, frequency and pulse-width may bevaried as required to achieve the desired result, based on the surgeon'sclinical experience.

DETAILED DESCRIPTION OF THE INVENTION

The method of the present invention initially produces a subcutaneoustunnel or cavity through the tissue as the tip of the optical fiber ismoved forwardly during the advancement stage, or rearwardly during thewithdrawal stage, usually while emitting light energy at a relativelylow energy level and a relatively short pulse width. However, in somecases, for example, if extremely thin skin could be damaged by emittinglight energy during advancement or withdrawal, the tip of the opticalfiber can be advanced or withdrawn without emitting light energy.

The selected area can be treated by repeated advancement and withdrawalcycles of the tip of the optical fiber as appropriate. Each cycle can bedirected at the same or a different radial angle. However, to avoiddamage to blood vessels which can be situated substantially normal tothe skin's surface, the optical fiber is moved unidirectionally ratherthan so as to sweep laterally through a sector like a windshield wiper.Advancement and withdrawal cycles are repeated as appropriate throughother openings within the selected region, until the entire region hasbeen treated.

Tissue can be removed or affected by several processes, includingvaporization; cross linkage, which produces shrinkage; disruption ofcellular membranes; desiccation of fat cells; lipolysis or melting offat cells; melting and fusion of tissue components (welding) anddenaturation or coagulation of proteins. Little bleeding occurs duringsuch processes due to the hemostasis produced by the effects of theapplied light energy. The effects produced depend on the wavelength andenergy level used. The process of tissue ablation requires relativelyhigher energy levels. Tissue welding may be used to join opposed tissuesurfaces at relatively low energy levels, without the need for suturesand their subsequent removal.

Blood and tissue coagulation is produced by heating the tissue to atleast about 62 degrees Celsius. Tissue vaporization or ablation isproduced by heating the tissue to at least about 100 degrees Celsius,causing the water in the cells to turn into steam. The small volume ofsteam produced is rapidly cooled by interaction with the tissue, andquickly condenses. Tissue disruption may also be caused by attendantconcurrent acoustic effects of laser energy emission.

The physiological response of the treated area progresses through acontinuum of at least three phases of wound healing after superficial orpercutaneous laser treatment. First, there is an edema phase, seen inmany cases within about 10 days after treatment. The sequence of eventsgenerally follows a course including two days of swelling and two daysof subsidence. Usually swelling is less pronounced after treatment witha holmium laser than after treatment with a CO₂ laser. The second phaseis characterized by the proliferation of fibroblasts. The third phase isthe resolution phase in which tissue remodeling takes place.

The tissue in the region to be treated subcutaneously is preferablyhydrated before laser treatment by the injection of water or an aqueoussaline solution. The water or aqueous saline solution used for thispurpose may include an acceptable local anesthetic. The overalltreatment parameters of energy levels, pulse width and frequencytypically used in illustrative procedures are tabulated in Table 1,below.

In each case, for penetration of the skin, the optical fiber waspositioned perpendicular to the skin, and a very low level of lightenergy was emitted while very gentle pressure was applied. Typicalparameters used for skin penetration were 3-10 mJ/pulse, preferablyabout 5 mJ/pulse, frequency of about 20-60 Hz and pulse width of about40-80 μS, although skin penetration of the fiber optic can also beachieved using lower or higher energies.

Similar energy parameters may be used to prevent or minimize tissueadherence while advancing the fiber to the treatment site or withdrawingthe fiber from the treatment site. The preferred energy parameters fortreatment at the site or along a tissue track, are set forth in Table 1.

TABLE 1 Preferred Parameters for Holmium Laser Treatment in SelectedProcedures PULSE FREQUENCY ENERGY WIDTH PROCEDURE Hz mJ/Pulse (μS) UpperBlepharoplasty 20-60 5-40 50-80 Lower Blepharoplasty 20-60 5-40 40-70Vein Coagulation 20-60 5-40 70-90 Skin Wrinkle Removal 20-60 5-40 40-70Telangiectasia 20-60 5-20  40-100

The laser tissue effect on the selected tissue site can be controlled bymodulating the energy per pulse, repetition rate and/or pulse width ofthe emitted laser energy.

EXAMPLE 1 Percutaneous Localized Treatment Parallel to the Skin Surface

The areas selected for treatment were first hydrated by an injection ofwater, an aqueous saline solution, or, preferably, an aqueous salinesolution containing an appropriate local anesthetic. The injected liquidserved to absorb excess light energy and heat to cool the tissue, and toprovide a buffer zone, which is especially useful in some locations,such as around the eyes.

The tip of the optical fiber was placed on the skin surface, at about a90 degree angle to the skin surface. The optical fiber was a bareoptical fiber of about 100 μm to about 365 μm in core diameter,preferably about 200 μm core diameter. The tip pierced the skin and wasadvanced into the subcutaneous tissue while emitting laser energy atabout 5 mJ/pulse, a pulse width of about 40 to about 70 μS at afrequency of about 20 to about 60 Hz. Low energies were used to minimizeadverse thermal effects to the skin, such as scarring, depigmentation orhyperpigmentation, at the site of entry.

After insertion of the tip of the optical fiber though the skin, thefiber was turned so that it was roughly parallel to the plane of theskin surface. The fiber was advanced and withdrawn repeatedly as neededto treat the selected region. Energy emission was increased after theinitial advancement stage to a therapeutic level of about 5 to about 50mJ/pulse, depending on the diameter of the fiber, smaller fibersrequiring less energy. Preferably, about 20 mJ/pulse was used at aboutthe same pulse width and frequency. The optical fiber was moved axiallyto and from, but not swept laterally like a windshield wiper. Thetreatment of a selected area continued until audible cavitation sounds(“popping”) ceased. Such cavitation sounds signalled the destruction ofthe fat present at the site (lipolysis) and the heating of the collagen.The optical fiber was then withdrawn from the skin, while continuing toemit energy at or below the therapeutic level, in order to minimize theamount of tissue adhering to the tip of the optical fiber.

This method has been used when the primary objective is the removal offat or the coagulation of blood vessels, with a secondary objective oftightening the skin. This method is appropriate, for example, forlipolysis of the fat pads and tightening (blepharoplasty) of the upperand lower eyelids, removal of nasal labial folds, removal of perioraland periorbital wrinkles; treatment of marionette lines and wrinkles ofthe ear lobes; neck lifts and lip lifts. This method may also be usedfor coagulation of telangiectasias, varicose and spider veins,hemangiomas and rosacea.

EXAMPLE 2 Percutaneous Localized Treatment Non-parallel to Skin Surface

The method of Example 1 was used with the modification that the opticalfiber was directed to the treatment site or used along a treatment trackthat was not parallel to the plane of the skin surface. This method isappropriate, for example, for the treatment of polly beak, wherein theshape of the nose is lifted and reshaped as desired by producing tissueshrinkage combined with lipolysis. For this purpose, the frequency usedwas about 20 to about 60 Hz; all other parameters were the same as usedin Example 1. This method is useful when the primary objective is theremoval of fat or removal of excess vascularization, with a secondaryobjective of tissue shrinkage to tighten the skin.

EXAMPLE 3 Tattoo Removal

Tattoo removal is accomplished by inserting the tip of the optical fiberthrough the skin in the pigmented area, at the fiber penetration energyparameters as described above, keeping the optical fiber perpendicularto the skin or tilting it at an angle substantially parallel to the skinand advancing and withdrawing the optical fiber while emitting energy atthe parameters as described in Example 1. Subsequent additionalpenetrations are made until the entire pigmented area is treated.

EXAMPLE 4 Incision (Internal Weir)

A bare optical fiber about 365 μm in diameter was inserted at the baseof the nostril. The method of Example 1 was used to create awedge-shaped opening or channel; the parameters were: about 10 to about50 mJ/pulse, preferably about 20 mJ/pulse, pulse width 50-70 μS andfrequency about 60 Hz. The edges of the channel were sutured together toreduce the size of the nostril opening.

EXAMPLE 5 Cartilage Vaporization, Bone Reduction

This method is useful for rhinoplasty (commonly referred to as a nosejob), which can be performed without postoperative bruising and blackeyes. A series of holes are made through the skin and throughcartilaginous and bony tissue using the optical fiber. The holes areplaced at or around the nose ridge protrusion in a configuration likethe perforations at the edges of a postage stamp. During the entryphase, the tip of the 200 or 365 μm bare optical fiber is placed at a 90degree angle relative to the skin. Low energies (about 5 mJ/pulse), areused to minimize adverse thermal effects on the skin at the entrancepoint of the optical fiber.

Therapy is administered by advancing the fiber internally throughcartilaginous and/or bony tissue. Energy parameters for therapy are15-40 mJ/pulse, 40-70 μS pulse width, at 20-60 Hz. After the “postagestamp” configuration is completed, external pressure is applied to the“postage stamp” to dislocate it from its original structuralconnections. The cartilaginous/bone fragment may be left in the body tobe naturally absorbed over time.

EXAMPLE 6 Coagulation of Varicose Veins

This method is useful for treatment of varicose veins. The areasurrounding the veins to be treated was anesthetized. The optical fiber,preferably a bare optical fiber, about 200 μm to about 365 μm indiameter, was placed on the skin above one end of the visible portion ofthe vein to be treated. The optical fiber penetrated the surface of skinat about a 90 degree angle and entered the vein, using parameters ofabout 5 mJ/pulse, 50-90 μS pulse width and 20-60 Hz. The energy wasincreased to about 5-25 mJ/pulse, preferably about 15 mJ/pulse, with theoptical fiber tip within the vein. Treatment was continued until thevein was coagulated. After the treatment, the tip of the optical fiberwas withdrawn while lasing at the therapeutic parameters, i.e. about5-25 mJ/pulse, preferably about 15 mJ/pulse, 50-90 μS pulse width and20-60 Hz. The treatment was repeated at the other end of the visibleportion of the varicose vein.

The foregoing is intended to be illustrative of the present invention,but not limiting. Numerous variations and modifications of treatmentparameters and energy sources may be utilized without departing from thespirit and scope of this invention.

What is claimed is:
 1. A method for percutaneous laser treatment of apatient having a condition requiring treatment, comprising the steps of:selecting an area to be treated; selecting a source of holmium laserenergy capable of stable energy emission of less than about 500milliJoules per pulse; selecting an optical fiber of appropriate corediameter said optical fiber having a tip; inserting the tip of theoptical fiber through the patient's skin into tissue; advancing the tipof the optical fiber through the tissue; treating the tissue by emittingthe holmium laser energy through the tip of the optical fiber at anenergy level less than about 200 milliJoules per pulse, with a pulsewidth less than about 200 microseconds and at an energy emissionfrequency of greater than about 5 Hertz while treating the tissue; andwithdrawing the tip of the optical fiber through the tissue.
 2. Themethod of claim 1, further comprising the step of emitting the holmiumlaser energy through the tip of the optical fiber at an energy levelless than about 200 milliJoules per pulse, with a pulse width less thanabout 200 microseconds and at an energy emission frequency of greaterthan about 5 Hertz while advancing the tip of the optical fiber.
 3. Themethod of claim 2 wherein the pulsed holmium laser energy is emittedthrough the tip of the optical fiber at a selected energy level lessthan about 100 milliJoules per pulse, with a pulse width less than 100microseconds and at an energy emission frequency greater than about 20Hertz while the tip of the optical fiber is advanced through the tissue.4. The method of claim 2 wherein the energy emission frequency while thetip of the optical fiber is advanced through tissue is about 20 to about80 Hertz.
 5. The method of claim 2 wherein the energy emission levelwhile the tip of the optical fiber is advanced through tissue is about 5milliJoules per pulse to about 50 milliJoules per pulse.
 6. The methodof claim 2 wherein the energy emission frequency while the tip of theoptical fiber is advanced through tissue is about 20 to 80 Hertz.
 7. Themethod of claim 1, further comprising the step of emitting the holmiumlaser energy through the tip of the optical fiber at an energy levelless than about 200 milliJoules per pulse, with a pulse width less thanabout 200 microseconds and at an energy emission frequency of greaterthan about 5 Hertz while withdrawing the tip of the optical fiber. 8.The method of claim 7 wherein the energy emission level while the tip ofthe optical fiber is withdrawn through tissue is about 5 milliJoules perpulse to about 50 milliJoules per pulse.
 9. The method of claim 7wherein the energy emission frequency while the tip of the optical fiberis withdrawn through tissue is about 20 to about 80 Hertz.
 10. Themethod of claim 1 further comprising the step of emitting light energyfrom the tip of the optical fiber while the tip of the optical fiber isinserted through the skin at an energy level of about 3 milliJoules perpulse to about 20 milliJoules per pulse.
 11. The method of claim 10wherein the energy emission frequency while the tip of the optical fiberis inserted through the skin is about 20 to 80 Hertz.
 12. The method ofclaim 1 wherein the energy emission level while the tip of the opticalfiber is advanced through the tissue is about 3 milliJoules per pulse toabout 20 milliJoules per pulse.
 13. The method of claim 1 wherein thepulse width is 5 to 100 microseconds.
 14. The method of claim 1 whereinthe tissue is skin tissue.
 15. The method of claim 1 wherein the tissueis tissue underlying the skin.
 16. The method of claim 1 wherein thecondition requiring treatment is blepharochalasis.
 17. The method ofclaim 1 wherein the condition requiring treatment is dermochalasis. 18.The method of claim 1 wherein the condition requiring treatment isturkey neck.
 19. The method of claim 1 wherein the condition requiringtreatment is rosacea.
 20. The method of claim 1 wherein the conditionrequiring treatment is plantar warts.
 21. The method of claim 1 whereinthe condition requiring treatment is keloid scars.
 22. The method ofclaim 1 wherein the condition requiring treatment is telangiectasia. 23.The method of claim 1 wherein the condition requiring treatment iswrinkles.
 24. The method of claim 1 wherein the condition to be treatedis unwanted hair follicles.
 25. The method of claim 1 wherein thecondition to be treated is the pigmented area of a tattoo.
 26. Themethod of claim 1 wherein the condition requiring treatment ismarionette lines.
 27. The method of claim 1 wherein the conditionrequiring treatment is basal cell carcinoma.
 28. The method of claim 1wherein the condition requiring treatment is acne scars.
 29. The methodof claim 1 wherein the condition requiring treatment is chicken poxscars.
 30. The method of claim 1 wherein the condition requiringtreatment is age spots.
 31. The method of claim 1 wherein the conditionrequiring treatment is hemangioma.
 32. The method of claim 1 wherein thecondition requiring treatment is port wine stains.
 33. The method ofclaim 1 wherein the condition requiring treatment is hyperpigmentation.34. The method of claim 1 wherein the condition requiring treatment isvaricose veins.
 35. The method of claim 1 wherein the conditionrequiring treatment is polly beak.
 36. The method of claim 1, whereinemitting the holmium laser energy occurs while advancing and withdrawingthe tip.